ABSTRACT

What from this Field Guide should people take into the field with them? Faced with rubble of human error, what core rules of engagement should people remember? This chapter is a compilation of the most important lessons from the Field Guide. It gives readers a brief overview of the do's and don'ts of a proper human error analysis. Remember to see each "human error" — under whatever traditional or fashionable label—as the beginning of readers investigation, or the beginning of a new part, not as the conclusion. The debate, and the basic distinction in it, oversimplifies the challenges before us if people really want to understand the complex dynamics that accompany and produce human error. People are neither just sinners nor simply saints—at best they are both. Safety are emerging features; they are by-products of entire systems and how the function in a changing, uncertain and resource-constrained world.